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Surgical Management of Gastric Torsion
Symposium on Surgical Techniques
Surgical Management of Gastric Torsion John Parks, D.V.M.*
There are only a few conditions, other than trauma, that are as acutely devastating to the patient as the gastric dilatation-torsion complex. Successful management is dependent on rapid diagnosis, emergency decompression, intensive treatment for shock and surgical correction. The surgical management of gastric torsion involves procedures performed to correct the acute pathologic state of gastric distension and to achieve gastric reposition, and procedures designed to reduce recurrence of the condition. On occasion, devitalized tissue, primarily of the spleen and stomach, must also be managed. Regardless of the surgical procedure performed, a high mortality rate can be expected because of the severe nature of the condition and the associated stress of surgery. Those surviving surgery face a high chance of recurrence, reported as 72 per cent in one study. 8 These risks should be recognized before any procedure is performed.
DECOMPRESSION Decompression of the dilated stomach should be attempted immediately. Preferably the procedure selected should not add to the respiratory or cardiovascular embarassment of the patient and should be rapidly executed while other emergency measures are being instituted. The decompression procedure should also avoid peritoneal contamination, if possible. Of the commonly employed procedures of gastric intubation, gastrocentesis, gastrotomy, and gastrostomy, only gastrostomy meets these criteria. *Staff Surgeon, Veterinary Hospital for Special Services, Mt. Kisco, New York; Diplomate, American College of Veterinary Surgeons
Veterinary Clinics of North America: Small Animal Practice- Vol. 9, No. 2, May 1979
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jOHN PARKS
GASTRIC INTUBATION
This procedure involves the oral passage of a pliable vinyl stomach tube of moderate firmness. Gastric contents can then be siphoned off and any remaining food debris flushed out by lavage. Large volumes of a physiologic saline solution are considered most correct as a lavage medium; however, tap water at body temperature has proved to be equally satisfactory. The main disadvantages of gastric intubation are the added respiratory distress of restraint and tube passage, especially if sedation or anesthetics are administered, and the threat of perforation of the gastric wall by the tube. It is also impossible in some patients to pass the tube into the stomach. If sedatives are required, it is critical for the surgeon to choose a drug that causes as little central respiratory depression as possible. If general anesthetics are administered, tracheal intubation and assisted ventilation are essential. The intravenous administration of ketamine hydrochloride (4 mg/kg of body weight) and diazepam (0.25 mg/kg of body weight), and a vagolytic drug such as atropine will provide both adequate restraint and muscle relaxation without severe central nervous system depression. Animals so treated should be intubated and ventilated with oxygen. Perforation of the gastric wall by the tube can be caused by traumatic passage but more often is the result of devitalization of the gastric wall from distention. The greater curvature of the gastric fundus, that area perfused by the left gastroepiploic artery, is the usual site of perforation and necrosis even in the absence of stomach tube passage. Cautious passage of a well-lubricated tube premeasured to reach just beyond the entrance to the gastric cardia will help minimize the risk. The tube should not be forced through the cardia if resistance is met; rather, inflation of the distal esophagus by blowing air into the stomach tube will often cause relaxation and the tube can then be advanced into the stomach. Once the stomach is emptied and lavaged, barium should be instilled and radiographs taken to assess position and perforation. Decompression can be maintained via the oral route by creating a pharyngostomy to secure the tube. 3 While the patient is being stabilized, further accumulation of gas or fluid is prevented by continual decompression.
GASTROCENTESIS
If performed, gastrocentesis should be done high through either flank with a 16- or 18-gauge trochar. The procedure is recommended only as an emergency maneuver when other routes of decompression are unavailable. The procedure has an inherent high risk of peritone-
SuRGICAL MANAGEMENT oF GASTRIC ToRSION
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al contamination, and patients so treated should be explored for contamination after stabilization is achieved. Another route of decompression should be obtained once the initial gas distention is relieved by gastrocentesis.
GASTROTOMY
Gastrotomy can hardly be considered to be the ideal method of decompression. The time spent in surgical preparation and the depressant actions of general anesthetics contraindicate this procedure for emergency decompression. If gastrotomy is elected as an emergency decompression procedure, stabilization of the patient must be achieved on the operating table with massive doses of intravenous fluids and sodium bicarbonate. The patient should be mechanically or manually ventilated throughout the procedure. The stomach should be decompressed and emptied by gastrotomy before any derotation is attempted. A pharyngostomy tube, or preferably a gastrostomy tube, should be placed to allow a route for postoperative decompression.
GASTROSTOMY
A right paracostal gastrostomy performed under local anesthesia has been described and evaluated as a decompression method. 6 • 7 Minimal surgical time and risk and the avoidance of general anesthesia and peritoneal contamination are the advantages of this procedure for the patient who cannot be rapidly and safely intubated orally. Decompression can be maintained by gastrostomy while stabilization of the patient is achieved, and gastric vitality can be evaluated by examination of stomach fluid for obvious diagnostic and prognostic value. There is an apparent direct clinical relationship between mortality and gastric wall necrosis. If necrosis is detected, the patient should be taken to surgery for resection. It must be remembered that the purpose of this procedure is emergency decompression. Once the patient has been stabilized, definitive surgery must be performed to repair the gastrostomy, reposition the stomach, and perform any prophylactic procedures. The only major disadvantage of this technique would be the delay in gastric resection in those cases of impending perforation. SURGICAL CORRECTION After decompression and shock resuscitation have stabilized the patient, definitive surgical correction should be performed. Ideally, a
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complete biochemical profile, blood count, clotting survey, and electrocardiogram should be performed to alert the surgeon to any anesthetic and surgical risks. During surgery the patient's electrocardiogram should be monitored closely for the presence of cardiac arrhythmias. The abdomen should be explored for the purposes of organ reposition, gastrostomy repair, inspection and resection of devitalized tissue, and the performance of prophylactic procedures. Prophylactic procedures advocated to reduce recurrence include pyloroplasty, splenectomy, gastropexy, gastrectomy, and tube gastrostomy. Although none of these procedures in themselves is 100 per cent effective in preventing gastric torsion, there does appear to be a lower recurrence rate when several procedures are performed. 8
PYLOROPLASTY
This has been advocated to encourage more rapid gastric emptying and reduce gastric distention; this seems reasonable especially in the presence of pyloric pathology. 3 The procedures chosen should be the least traumatic and most rapidly performed. The Fredet-Ramstedt or Heineke-Mikulicz procedures meet these requirements, although the latter technique involves luminal exposure with the added risk of leakage.
SPLENECTOMY
Splenectomy is advocated only in those instances in which significant thrombosis and devitalization are present. 2 The gastric wall should also be closely inspected for devitalization in patients with splenomegaly and thrombosis. The presence of massive splenic thrombosis and gastric wall necrosis should alert the surgeon to the likelihood of clotting derangements and cardiac arrhythmias. 8
GASTROPEXY
Gastropexy is the surgical fixation of the stomach wall to the abdominal wall to encourage adhesion formation and thus limit gastric mobility. Clinically, gastropexy procedures rarely hold beyond the operating table because of the strong muscular contraction of the stomach and apposed abdominal wall. A permanent gastropexy procedure and gastrocolopexy procedure have been described and performed on a clinical basis with success.L 2 These procedures require too much surgical time and tissue compromise for routine use in the critical patient. They may be of
SuRGICAL MANAGEMENT oF GASTRIC ToRSION
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definite value in the patient with chronic bloat, when other procedures have been unsuccessful.
GASTRECTOMY
As already stated, gastrectomy should be performed to remove areas of necrosis. In some patients, removal of more than 50 per cent of the stomach may be necessary, as large areas of devitalized tissue not resected are potential sources of clotting derangements and cardiac arrhythmias. The defect created should be closed with healthy tissue in a two-layer pattern to guarantee an adequate seal. Partial removal of the gastric fundus has also been advocated in patients with large, dilated, atonic stomachs as a result of chronic bloat.
TUBE GASTROSTOMY
Gastrostomy is the creation of an artificial opening in the stomach wall for decompression and feeding purposes. A traction tube gastrostomy further serves to bind the stomach wall to the abdominal wall allowing adhesion formation which gastropexy alone fails to accomplish. This procedure requires very little surgical time, does not compromise a major portion of the stomach wall, and provides a comfortable route for postoperative decompression. Of all the prophylactic procedures mentioned, only traction tube gastrostomy has significantly reduced the recurrence of gastric volvulus at The Animal Medical Center. The Center uses the Dragstedt modification of the Stamn gastrostomy. With this procedure, using a Foley catheter,* traction can be applied to the stomach to restrict motion and allow adhesion formation. The procedure is performed either on an elective basis or following emergency surgery. Gastric repositioning and pyloroplasty should be performed prior to gastrostomy. A 24- to 26- French Foley catheter is forced through an abdominal wall stab wound placed perimedian to the right of the ventral midline, approximately 4 em caudal to the last rib (Fig. lA). Care must be taken to avoid lacerating the cranial epigastric vessels. The stab wound size should not exceed the diameter of the tube and should penetrate all layers of the abdominal wall in a direct manner (Fig. lB). Next, the greater omentum near the pyloric antrum is mobilized to allow the tube to perforate several of its layers before placement into the stomach (Figs. l,C and D). A pursestring suture of 0 silk is then placed in the antral region of the stomach (Fig. 2A). A stab *Imex Foley Catheter- Iminmed Corporation. New York.
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JOHN PARKS
Figure l. A , A Foley catheter (C) is forced throu gh a p erimedian abdomin al stab wound. B , A Foley catheter (C) is drawn into the abdomen . C, The greater omentum (0) is perforated by the Foley catheter (C). D, Gastric antrum (A), pylorus (P), Foley catheter (C), a nd greater omentu m (0).
Figure :2. A , Silk pursestring suture is placed in the gastric antrum (A). B , A stab wound is mad e in the wall of the stomach.
SuRGICAL MANAGEMENT O F GASTRIC ToRSION
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wound is made in the center of the stomach wall surrounded by the pursestring suture, and the tip of the catheter is forced into the gastric lumen (Fig. 2B). The bulb of the Foley catheter is inflated (Fig. 3A ), and the pursestring suture tied to form a secure seal around the tube (Fig. 3B ). By applying traction on the catheter, the gastric antrum is drawn to the abdominal wall and a gastropexy with 0 silk suture is performed (Fig. 3C). After routine abdominal closure, the gastrostomy tube is then firmly secured to the skin, maintaining the traction between the stomach and abdominal wall (Fig. 3D). Postoperatively, there is minimal care and discomfort involved with maintenance of a gastrostomy tube. T he tube should be capped to prevent loss of gastric fluid unless decompression is indicated by distention. A nonconstricting abdominal bandage is applied to prevent removal of the tube by the patient. Animals are offered o nly water on the first day after surgery; small frequent meals of a nonexpandable food are begun on the second postoperative d ay.
Figure 3. A, A Foley catheter bulb is inflated with saline. B , A Pursestring suture is tied (arrow ) to form a seal around the Foley cath eter (C). C, T h e gastric a ntrum (A) is d rawn to the abdo minal wall (W) a nd gastropexy is pe rfor med (arrows). D , A Foley catheter (C) is secu red to the skin, mainta ining traction.
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Figure 4. Fibrous adhesion bands (arrows) running from the gastric antrum (A) to the abdominal wall (W).
The tube should remain in place for five to seven days before removal. The patient can be treated at home during this time unless complications are noted. When the tube is removed, the Foley bulb should first be deflated. The fistula is treated as an open wound with only local cleaning. It can be expected to drain for a few days and then seal over. This procedure has been highly successful in preventing recurrence of torsion in a large series of cases at The Animal Medical Center over the past four years. Firm adhesion bands between the stomach and abdominal wall have been documented in patients reoperated for conditions unrelated to gastric torsion. These adhesions limit rotation of the antral region of the stomach yet do not appear to interfere with gastric function. Gastric dilatation without rotation has occurred in a few patients despite this procedure. These animals do not seem to be overly distressed with the distention, and decompression by the oral route effectively manages the condition.
SUMMARY Considerable investigation has been devoted to the gastric dilatation-torsion complex. An ad equate expla nation of its cause has yet to be made, or a means of prevention described. We do know of its highly lethal nature, especially if not aggressively treated, of the high incidence of r ecurrence, and of the associated pathophysiology. 4 ' 5 ' s, 9 As surgeons, we must approach the patient in an aggressive systematic manner. Decompression and patient stabilization must be achieved prior to d efinitive surgical management. T h e surgery planned must correct the obvious pathologic state and include procedures designed to prevent recurrence of this condi-
SURGICAL MANAGEMENT OF GASTRIC TORSION
267
tion. The tube gastrostomy technique promotes gastric fixation by dense adhesion bands exceeding that attainable by gastropexy alone. The procedure is easy to perform, requires little surgical time, and does not appear to be discomforting to the patient. In addition, the tube gastrostomy acts as a convenient decompressive pathway during the postoperative period, circumventing gastric intubation or pharyngostomy tube placement should distention occur.
REFERENCES l. Betts, C. W., Wingfield, W. R., and Rosen, E.: Permanent gastropexy as a prophylactic measure against gastric volvulus. J.A.A.H.A., 12: 177, 1976. 2. Christie, T. R., and Smith, C. W.: Gastrocolopexy for prevention of recurrent gastric volvulus. J.A.A.H.A., 12:173, 1976. 3. DeHoff, W. D., and Greene, R. W.: Gastric dilation and the gastric torsion complex. VET. CuN. NoRTH AM., 2:141, 1972. 4. Merkley, D. F., Howard, D. R., Eyster, G. E., et al.: Experimentally induced acute gastric dilatation in the dog: Cardiopulmonary effects. J.A.A.H.A., 12:143, 1976. 5. Merkley, D. F., Howard, D. R., Krehbiel,]. D., et al.: Experimentally induced acute gastric dilatation in the dog: Clinicopathologic findings. J.A.A.H.A., 12:149, 1976. 6. Pass, M. A., and Johnston, D. E.: Treatment of gastric dilation-torsion in the dog: Gastric decompression by gastrostomy under local analgesia. ]. Small Anim. Pract., 14:131, 1973. 7. Walshaw, R., and Johnston, D. E.: Treatment of gastric dilatation-volvulus by gastric decompression and patient stabilization before major surgery. J.A.A.H.A., 12:162, 1976. 8. Wingfield, W. R., Betts, C. W. and Greene, R. W.: Operative technique and recurrence rates associated with gastric volvulus in the dog. ]. Small Anim. Pract., 16:427, 1975. 9. Wingfield, W. E., Betts, C. W., and Rawling, C. A.: Pathophysiology associated with gastric-dilatation-volvulus in the dog. J.A.A.H.A., 12:136, 1976.
County Animal Clinic 1574 Central Av. Yonkers, New York 10710 end of article no. 6
Surgical Management of Gastric Torsion John Parks, D.V.M.*
There are only a few conditions, other than trauma, that are as acutely devastating to the patient as the gastric dilatation-torsion complex. Successful management is dependent on rapid diagnosis, emergency decompression, intensive treatment for shock and surgical correction. The surgical management of gastric torsion involves procedures performed to correct the acute pathologic state of gastric distension and to achieve gastric reposition, and procedures designed to reduce recurrence of the condition. On occasion, devitalized tissue, primarily of the spleen and stomach, must also be managed. Regardless of the surgical procedure performed, a high mortality rate can be expected because of the severe nature of the condition and the associated stress of surgery. Those surviving surgery face a high chance of recurrence, reported as 72 per cent in one study. 8 These risks should be recognized before any procedure is performed.
DECOMPRESSION Decompression of the dilated stomach should be attempted immediately. Preferably the procedure selected should not add to the respiratory or cardiovascular embarassment of the patient and should be rapidly executed while other emergency measures are being instituted. The decompression procedure should also avoid peritoneal contamination, if possible. Of the commonly employed procedures of gastric intubation, gastrocentesis, gastrotomy, and gastrostomy, only gastrostomy meets these criteria. *Staff Surgeon, Veterinary Hospital for Special Services, Mt. Kisco, New York; Diplomate, American College of Veterinary Surgeons
Veterinary Clinics of North America: Small Animal Practice- Vol. 9, No. 2, May 1979
259
260
jOHN PARKS
GASTRIC INTUBATION
This procedure involves the oral passage of a pliable vinyl stomach tube of moderate firmness. Gastric contents can then be siphoned off and any remaining food debris flushed out by lavage. Large volumes of a physiologic saline solution are considered most correct as a lavage medium; however, tap water at body temperature has proved to be equally satisfactory. The main disadvantages of gastric intubation are the added respiratory distress of restraint and tube passage, especially if sedation or anesthetics are administered, and the threat of perforation of the gastric wall by the tube. It is also impossible in some patients to pass the tube into the stomach. If sedatives are required, it is critical for the surgeon to choose a drug that causes as little central respiratory depression as possible. If general anesthetics are administered, tracheal intubation and assisted ventilation are essential. The intravenous administration of ketamine hydrochloride (4 mg/kg of body weight) and diazepam (0.25 mg/kg of body weight), and a vagolytic drug such as atropine will provide both adequate restraint and muscle relaxation without severe central nervous system depression. Animals so treated should be intubated and ventilated with oxygen. Perforation of the gastric wall by the tube can be caused by traumatic passage but more often is the result of devitalization of the gastric wall from distention. The greater curvature of the gastric fundus, that area perfused by the left gastroepiploic artery, is the usual site of perforation and necrosis even in the absence of stomach tube passage. Cautious passage of a well-lubricated tube premeasured to reach just beyond the entrance to the gastric cardia will help minimize the risk. The tube should not be forced through the cardia if resistance is met; rather, inflation of the distal esophagus by blowing air into the stomach tube will often cause relaxation and the tube can then be advanced into the stomach. Once the stomach is emptied and lavaged, barium should be instilled and radiographs taken to assess position and perforation. Decompression can be maintained via the oral route by creating a pharyngostomy to secure the tube. 3 While the patient is being stabilized, further accumulation of gas or fluid is prevented by continual decompression.
GASTROCENTESIS
If performed, gastrocentesis should be done high through either flank with a 16- or 18-gauge trochar. The procedure is recommended only as an emergency maneuver when other routes of decompression are unavailable. The procedure has an inherent high risk of peritone-
SuRGICAL MANAGEMENT oF GASTRIC ToRSION
261
al contamination, and patients so treated should be explored for contamination after stabilization is achieved. Another route of decompression should be obtained once the initial gas distention is relieved by gastrocentesis.
GASTROTOMY
Gastrotomy can hardly be considered to be the ideal method of decompression. The time spent in surgical preparation and the depressant actions of general anesthetics contraindicate this procedure for emergency decompression. If gastrotomy is elected as an emergency decompression procedure, stabilization of the patient must be achieved on the operating table with massive doses of intravenous fluids and sodium bicarbonate. The patient should be mechanically or manually ventilated throughout the procedure. The stomach should be decompressed and emptied by gastrotomy before any derotation is attempted. A pharyngostomy tube, or preferably a gastrostomy tube, should be placed to allow a route for postoperative decompression.
GASTROSTOMY
A right paracostal gastrostomy performed under local anesthesia has been described and evaluated as a decompression method. 6 • 7 Minimal surgical time and risk and the avoidance of general anesthesia and peritoneal contamination are the advantages of this procedure for the patient who cannot be rapidly and safely intubated orally. Decompression can be maintained by gastrostomy while stabilization of the patient is achieved, and gastric vitality can be evaluated by examination of stomach fluid for obvious diagnostic and prognostic value. There is an apparent direct clinical relationship between mortality and gastric wall necrosis. If necrosis is detected, the patient should be taken to surgery for resection. It must be remembered that the purpose of this procedure is emergency decompression. Once the patient has been stabilized, definitive surgery must be performed to repair the gastrostomy, reposition the stomach, and perform any prophylactic procedures. The only major disadvantage of this technique would be the delay in gastric resection in those cases of impending perforation. SURGICAL CORRECTION After decompression and shock resuscitation have stabilized the patient, definitive surgical correction should be performed. Ideally, a
262
joHN PARKS
complete biochemical profile, blood count, clotting survey, and electrocardiogram should be performed to alert the surgeon to any anesthetic and surgical risks. During surgery the patient's electrocardiogram should be monitored closely for the presence of cardiac arrhythmias. The abdomen should be explored for the purposes of organ reposition, gastrostomy repair, inspection and resection of devitalized tissue, and the performance of prophylactic procedures. Prophylactic procedures advocated to reduce recurrence include pyloroplasty, splenectomy, gastropexy, gastrectomy, and tube gastrostomy. Although none of these procedures in themselves is 100 per cent effective in preventing gastric torsion, there does appear to be a lower recurrence rate when several procedures are performed. 8
PYLOROPLASTY
This has been advocated to encourage more rapid gastric emptying and reduce gastric distention; this seems reasonable especially in the presence of pyloric pathology. 3 The procedures chosen should be the least traumatic and most rapidly performed. The Fredet-Ramstedt or Heineke-Mikulicz procedures meet these requirements, although the latter technique involves luminal exposure with the added risk of leakage.
SPLENECTOMY
Splenectomy is advocated only in those instances in which significant thrombosis and devitalization are present. 2 The gastric wall should also be closely inspected for devitalization in patients with splenomegaly and thrombosis. The presence of massive splenic thrombosis and gastric wall necrosis should alert the surgeon to the likelihood of clotting derangements and cardiac arrhythmias. 8
GASTROPEXY
Gastropexy is the surgical fixation of the stomach wall to the abdominal wall to encourage adhesion formation and thus limit gastric mobility. Clinically, gastropexy procedures rarely hold beyond the operating table because of the strong muscular contraction of the stomach and apposed abdominal wall. A permanent gastropexy procedure and gastrocolopexy procedure have been described and performed on a clinical basis with success.L 2 These procedures require too much surgical time and tissue compromise for routine use in the critical patient. They may be of
SuRGICAL MANAGEMENT oF GASTRIC ToRSION
263
definite value in the patient with chronic bloat, when other procedures have been unsuccessful.
GASTRECTOMY
As already stated, gastrectomy should be performed to remove areas of necrosis. In some patients, removal of more than 50 per cent of the stomach may be necessary, as large areas of devitalized tissue not resected are potential sources of clotting derangements and cardiac arrhythmias. The defect created should be closed with healthy tissue in a two-layer pattern to guarantee an adequate seal. Partial removal of the gastric fundus has also been advocated in patients with large, dilated, atonic stomachs as a result of chronic bloat.
TUBE GASTROSTOMY
Gastrostomy is the creation of an artificial opening in the stomach wall for decompression and feeding purposes. A traction tube gastrostomy further serves to bind the stomach wall to the abdominal wall allowing adhesion formation which gastropexy alone fails to accomplish. This procedure requires very little surgical time, does not compromise a major portion of the stomach wall, and provides a comfortable route for postoperative decompression. Of all the prophylactic procedures mentioned, only traction tube gastrostomy has significantly reduced the recurrence of gastric volvulus at The Animal Medical Center. The Center uses the Dragstedt modification of the Stamn gastrostomy. With this procedure, using a Foley catheter,* traction can be applied to the stomach to restrict motion and allow adhesion formation. The procedure is performed either on an elective basis or following emergency surgery. Gastric repositioning and pyloroplasty should be performed prior to gastrostomy. A 24- to 26- French Foley catheter is forced through an abdominal wall stab wound placed perimedian to the right of the ventral midline, approximately 4 em caudal to the last rib (Fig. lA). Care must be taken to avoid lacerating the cranial epigastric vessels. The stab wound size should not exceed the diameter of the tube and should penetrate all layers of the abdominal wall in a direct manner (Fig. lB). Next, the greater omentum near the pyloric antrum is mobilized to allow the tube to perforate several of its layers before placement into the stomach (Figs. l,C and D). A pursestring suture of 0 silk is then placed in the antral region of the stomach (Fig. 2A). A stab *Imex Foley Catheter- Iminmed Corporation. New York.
264
JOHN PARKS
Figure l. A , A Foley catheter (C) is forced throu gh a p erimedian abdomin al stab wound. B , A Foley catheter (C) is drawn into the abdomen . C, The greater omentum (0) is perforated by the Foley catheter (C). D, Gastric antrum (A), pylorus (P), Foley catheter (C), a nd greater omentu m (0).
Figure :2. A , Silk pursestring suture is placed in the gastric antrum (A). B , A stab wound is mad e in the wall of the stomach.
SuRGICAL MANAGEMENT O F GASTRIC ToRSION
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wound is made in the center of the stomach wall surrounded by the pursestring suture, and the tip of the catheter is forced into the gastric lumen (Fig. 2B). The bulb of the Foley catheter is inflated (Fig. 3A ), and the pursestring suture tied to form a secure seal around the tube (Fig. 3B ). By applying traction on the catheter, the gastric antrum is drawn to the abdominal wall and a gastropexy with 0 silk suture is performed (Fig. 3C). After routine abdominal closure, the gastrostomy tube is then firmly secured to the skin, maintaining the traction between the stomach and abdominal wall (Fig. 3D). Postoperatively, there is minimal care and discomfort involved with maintenance of a gastrostomy tube. T he tube should be capped to prevent loss of gastric fluid unless decompression is indicated by distention. A nonconstricting abdominal bandage is applied to prevent removal of the tube by the patient. Animals are offered o nly water on the first day after surgery; small frequent meals of a nonexpandable food are begun on the second postoperative d ay.
Figure 3. A, A Foley catheter bulb is inflated with saline. B , A Pursestring suture is tied (arrow ) to form a seal around the Foley cath eter (C). C, T h e gastric a ntrum (A) is d rawn to the abdo minal wall (W) a nd gastropexy is pe rfor med (arrows). D , A Foley catheter (C) is secu red to the skin, mainta ining traction.
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jOHN PARKS
Figure 4. Fibrous adhesion bands (arrows) running from the gastric antrum (A) to the abdominal wall (W).
The tube should remain in place for five to seven days before removal. The patient can be treated at home during this time unless complications are noted. When the tube is removed, the Foley bulb should first be deflated. The fistula is treated as an open wound with only local cleaning. It can be expected to drain for a few days and then seal over. This procedure has been highly successful in preventing recurrence of torsion in a large series of cases at The Animal Medical Center over the past four years. Firm adhesion bands between the stomach and abdominal wall have been documented in patients reoperated for conditions unrelated to gastric torsion. These adhesions limit rotation of the antral region of the stomach yet do not appear to interfere with gastric function. Gastric dilatation without rotation has occurred in a few patients despite this procedure. These animals do not seem to be overly distressed with the distention, and decompression by the oral route effectively manages the condition.
SUMMARY Considerable investigation has been devoted to the gastric dilatation-torsion complex. An ad equate expla nation of its cause has yet to be made, or a means of prevention described. We do know of its highly lethal nature, especially if not aggressively treated, of the high incidence of r ecurrence, and of the associated pathophysiology. 4 ' 5 ' s, 9 As surgeons, we must approach the patient in an aggressive systematic manner. Decompression and patient stabilization must be achieved prior to d efinitive surgical management. T h e surgery planned must correct the obvious pathologic state and include procedures designed to prevent recurrence of this condi-
SURGICAL MANAGEMENT OF GASTRIC TORSION
267
tion. The tube gastrostomy technique promotes gastric fixation by dense adhesion bands exceeding that attainable by gastropexy alone. The procedure is easy to perform, requires little surgical time, and does not appear to be discomforting to the patient. In addition, the tube gastrostomy acts as a convenient decompressive pathway during the postoperative period, circumventing gastric intubation or pharyngostomy tube placement should distention occur.
REFERENCES l. Betts, C. W., Wingfield, W. R., and Rosen, E.: Permanent gastropexy as a prophylactic measure against gastric volvulus. J.A.A.H.A., 12: 177, 1976. 2. Christie, T. R., and Smith, C. W.: Gastrocolopexy for prevention of recurrent gastric volvulus. J.A.A.H.A., 12:173, 1976. 3. DeHoff, W. D., and Greene, R. W.: Gastric dilation and the gastric torsion complex. VET. CuN. NoRTH AM., 2:141, 1972. 4. Merkley, D. F., Howard, D. R., Eyster, G. E., et al.: Experimentally induced acute gastric dilatation in the dog: Cardiopulmonary effects. J.A.A.H.A., 12:143, 1976. 5. Merkley, D. F., Howard, D. R., Krehbiel,]. D., et al.: Experimentally induced acute gastric dilatation in the dog: Clinicopathologic findings. J.A.A.H.A., 12:149, 1976. 6. Pass, M. A., and Johnston, D. E.: Treatment of gastric dilation-torsion in the dog: Gastric decompression by gastrostomy under local analgesia. ]. Small Anim. Pract., 14:131, 1973. 7. Walshaw, R., and Johnston, D. E.: Treatment of gastric dilatation-volvulus by gastric decompression and patient stabilization before major surgery. J.A.A.H.A., 12:162, 1976. 8. Wingfield, W. R., Betts, C. W. and Greene, R. W.: Operative technique and recurrence rates associated with gastric volvulus in the dog. ]. Small Anim. Pract., 16:427, 1975. 9. Wingfield, W. E., Betts, C. W., and Rawling, C. A.: Pathophysiology associated with gastric-dilatation-volvulus in the dog. J.A.A.H.A., 12:136, 1976.
County Animal Clinic 1574 Central Av. Yonkers, New York 10710 end of article no. 6